Knowledge and preventive practices regarding COVID-19 disease among Ukrainian refugees in Poland

Russia’s invasion of Ukraine contributed one of the largest migration movements in the 21st century. Refugees may become a source of severe acute respiratory syndrome coronavirus 2 infections for the residents of host countries. The study aim was to assess knowledge and preventive practices regarding coronavirus disease 2019 (COVID-19) among Ukrainian refugees in Poland. The cross-sectional study was conducted between March and April 2022 among Ukrainian refugees registering consecutively in Zielona Góra, Poland. Knowledge and preventive practices were assessed by giving 1 point for each correct answer by anonymous, self-administered questionnaire. The response rate was 96%, 190 participated (mean age 37.8 ± 15.5 years; 57.9% females); 61.6% self-reported their socio-economic status (SES) as high, 38.9% reported high level of education. The mean COVID-19 knowledge score was 3.06 ± 1.95; 19.5% scored >50%. The knowledge level was higher among migrants with high SES (P = .003). The mean preventive practices score was 2.56 ± 1.38; 54.0% scored ≥ 60%. 40.5% declared social distancing, 62.6% followed coughing etiquette, 69.0% home isolate themselves during COVID-19. 57.9% always used masks in public space, however 74.2% wore masks with uncovered nose. Refugees with higher education, high SES and knowledge level had significantly greater preventive practices scores (P = .002; P = .02; P = .03, respectively). The knowledge and preventive practices level was insufficient. Educational campaigns oriented to raising knowledge and prevention behavior skills should be implemented, especially targeting high-risk groups to avoid spread of COVID-19.


Introduction
Before the Russian's invasion of Ukraine, 1.35 million migrants lived in Poland. [1]The Russian aggression in February 2022 caused enormous exodus of Ukrainians to neighboring countries, including Poland. [1]According to the latest report from August 2023, the Polish-Ukrainian border was crossed by 14.48 million war refugees, [2] 96% of them were females.Of note, almost a half (48%) declared Poland as the final destination country. [3]However, general mobilization into the Armed Forces and changes in the extent of war zone had caused migration's homecoming.Therefore, currently, it is difficult to estimate the Ukrainian's population size in Poland.Concerning the previous data, Ukrainian migrants are a mobile community with low immunization rates. [4,5]For instance, less than 40% of Ukrainians have received the coronavirus disease 2019 (COVID-19) vaccine in 2022. [5]This was an important factor which influenced epidemiological situation in the country: until March 7, 2023, Ukraine has reported 5.39 million severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and nearly 111,300 deaths. [6]Due to the large migration wave and relatively high vaccination hesitancy among refugees, there is difficult to provide efficient prevention regarding COVID-19 in the hosting countries. [7]efugees may become a potential source of infection for residents. [8]krainian refugees (UR) who came to Poland were located in the numerous refugee centers.Usually they stayed in large clusters, which may contribute to spread of infectious diseases, including air-borne infections.Only 34.6% of the Ukrainian population received complete primary series. [9]his is a poor result compared to the immunization rate in the European Union, which is 83.4%. [7]From July 2021 vaccinations in Ukraine also covered children and adolescents aged 12 to 18.In this age group, only 193,380 vaccinations with Comirnaty vaccine were performed. [10]The low vaccination coverage among Ukrainian citizens is mainly due to serious concerns about the side effects of the vaccine and its poor quality. [11]he latest report showed that refugees can use false vaccination certificates; this may have a significant impact on public health. [11]Current research shows that following nonspecific methods of SARS-CoV-2 infection prevention may decrease the number of COVID-19 cases [12] adequate knowledge may also have a significant impact on limiting the spread of infection. [13]ot much research on attitudes and knowledge regarding this issue has been carried out among UR to date, therefore we decided to conduct that cross-sectional study.The study aim was to assess knowledge and preventive practices regarding COVID-19 among UR in Poland.

Study design and setting
A cross-sectional study was conducted in March and April 2022 in the Zielona Gora City Hall Civil Affairs Department which is oriented to handling cases related to the legalization of stay of foreigners in Zielona Gora, Lubuskie province, Poland.Although it was available for all foreigners, at the time the study was conducted the vast majority of migrants were UR.

Study population
The study population consisted of UR, who came to Poland after the Russian aggression to Ukraine.Consecutive Ukrainians who registered in a refugee center were invited to participate in the study.Respondents were informed that participation was anonymous, voluntary and that they had full rights to withdraw from the study at any time.Inclusion criteria were as follows: • being a UR • signing an informed consent to participate.

Study instrument and data collection
Seven students of the medical faculty of the University of Zielona Góra, Poland, members of the Students' Research Group, were handling out questionnaires to Ukrainians.A self-administered anonymous questionnaire was used as the data collection instrument.[16][17] Filling out the questionnaire took about 5 to 10 minutes.The questionnaire consisted of 21 questions divided into 3 parts: demographic data (age, gender, residency, education, socio-economic status [SES], and marital status); knowledge about COVID-19; and attitudes toward COVID-19.We divided education into higher education level and lower education level.Higher education level means that participates graduated university.Knowledge about COVID-19 was assessed giving 1 point for each correct answer to 9 questions (a scale of 0-9).A total knowledge score was then calculated for each respondent.The higher the score, the better knowledge of COVID-19.Scores of 0 to 5 (≤55% of correct answers) were arbitrary taken as poor, 6 to 9 (more than 55% of correct answers) as adequate knowledge.Attitudes toward COVID-19 were assessed by giving 1 point for each correct answer to the 5 items regarding: following coughing etiquette; using masks in public spaces, wearing mask with covered nose, keeping social distance and practicing home isolation while experiencing SARS-CoV-2 infection syndromes.The scale measured attitudes from a minimum of 0 to a maximum of 5. Scores for individuals were summed up to give a total score.Scores of ≥3 points (≥60%) were taken as a adequate attitude level.
According to the rapport refugees population may have been around 575,100. [18]he representative target sample size was calculated with a sample size calculator. [19]This arrived at 384 participants, using a margin of error of ±5%, a confidence level of 95% and a 50% response distribution.
Anonymous cross-sectional surveys, like this one, do not require the consent of the Bioethical Committee Collegium Medicum University of Zielona Góra in Poland.
According to the statement posted on the official website of the Collegium Medicum of the University of Zielona Gora "A relevant bioethics committee consent is not required in the case of a survey involving the use of questionnaires used in accordance with their intended purpose; statistical analysis will be developed based on selected elements of the survey." [20]

Statistical analysis
Data were converted to a Microsoft Excel version 16.53 and analyzed using STATISTICA PL Version 13 (StatSoft Inc., 2017) and a statistical software package (R Foundation for Statistical Computing, Vienna, Austria). [21]Categorical variables were presented as frequencies with percentages to describe UR characteristics, and continuous data were given as means.Preventive practices regarding COVID-19 was our main variable.Demographic characteristics were assessed with bivariate analysis as follows: age (years), gender, residency in Ukraine (city of up to 50,000/>50,000 citizens), marital status (married-cohabitant/other), education level (higher/lower education) and COVID-19 knowledge level (adequate/poor).The Shapiro-Wilk test showed that variables were not normally distributed (P < .005),so the non-parametric tests were used to assess the significance of the difference.The Fisher's exact test were used for 2 group comparisons of categorical variables.For numerical variables, the Mann-Whitney test was used.A P value was statistically significant if <.05.To build a logistic regression model, [22] the set of predictors was used with the help of the R MASS package. [23]Final associations between predictors and the outcome adjusted for covariates were measured with the use of coefficients of a logistic regression model to evaluate any changes in the model.Regression results are presented as odds ratios (ORs).

Sociodemographic characteristics
The sociodemographic characteristics of the participants are presented in Table 1.Initially, 198 refugees were invited, 190 agreed to take part (the response rate was 96.0%).The mean age was 37.8 ± 15.7 years (range: 15-83 years); females accounted for 57.9%.More than a half of respondents (52.1%) were living in cities ≥50,000 inhabitants and were unmarried (55.8%).Almost two thirds (61.6%) self-assessed their SES as high; more than one third (39.0%) had a higher education level.

Knowledge on COVID-19
Participants were asked to self-assess their knowledge level about SARS-CoV-2/COVID-19; the answers were as follows: poor -11.1% (21/190) UR knowledge level is presented in Table 2.About twofifths knew the most effective type of mask, 54.7% indicated that COVID-19 is highly infectious.Less than 10% correctly recognized mode of transmission, 35.8% didn't know that some infected persons may be asymptomatic.Less than half of respondents (41.6%) correctly marked COVID-19 incubation period, 26.3% knew that SARS-CoV-2 doesn't leave lifelong immunity.About a quarter correctly recognized a higher COVID-19 mortality rate in older group then in younger people, 44.2% knew about an accessible drug reducing the risk of severe COVID-19.Only one-third (31.6%) knew that SARS-CoV-2 has animal origin.
Table 3 presents knowledge on COVID-19 among UR in Poland by selected variables.Participants with higher SES demonstrated greater knowledge (3.14 ± 1.94) than respondents with lower SES (2.92 ± 1.99); P = .003.There were no statistically significant differences between UR regarding age, gender, education, marital status, and residence in Ukraine.

Preventive practices
More than a half of UR (57.9%) used masks in the public space, however, about three-fourth of participants (74.2%) declared then they wore masks with uncovered nose.Almost two in three (62.6%)respondents followed coughing etiquette, only 40.5% kept social distancing.More than three-thirds (69.0%) were practicing home isolation while experiencing SARS-CoV-2 infection syndromes.
The mean practices score was 2.56 ± 1.38.Only 53.7% of respondents scored ≥60% of correct answers.Preventive practices score was significantly higher in the group with higher education level (2.95 ± 1.34) than with lower education level (2.31 ± 1.35) and with high SES (2.74 ± 1.35) than with low SES (2.26 ± 1.39); P = .002and P = .02,respectively.There were no statistically significant differences between attitudes scores in terms of age, gender, residence in Ukraine and marital status (Table 4).UR with higher COVID-19 knowledge level scored more regarding the preventive practices score (3.21 ± 0.98 vs 2.49 ± 1.40); P = .03.

Predictors of being adherent to preventive practices
Multiple logistic regression analysis regarding an association of being adherent to COVID-19 preventive practices with selected variables revealed that education status and knowledge level were independent positive predictors of presenting adequate practices (OR 2.19; P = .03and OR 4.01; P < .0001,respectively); Table 5.

Result overview
To the best of our knowledge, this was the first study about knowledge and preventive practices towards COVID-16 among UR in Poland.Previous studies among Ukrainian migrants were focused on vaccinations. [1,4]Our findings show that UR presented poor knowledge level about COVID-19 and declared inadequate attitudes regarding prevention practices, particularly those with lower education (OR = 2.2) and knowledge level (OR = 4.0), suggesting that well educated subjects with high knowledge would practice more preventive measures.

Knowledge towards COVID-19
According to the previous research, knowledge affects the formation of attitudes and practices. [24]Checking the knowledge level in migrants is important to detect gaps, which can be further fulfilled through tailored education campaigns.
Only one in five refugees answered correctly to at least half of the questions.[26][27] However, these studies were conducted on different group of participants (not targeting migrants) and used online questionnaires; this means that external sources of information could have been used.
Less than 1 in 10 migrants knew the mode of transmission COVID-19, which is alarming due to the fact that low knowledge can result in non-adherence to COVID-19 prevention methods.There is a risk that people with poor knowledge of transmission pathways could become a potential source of infection. [28]ewer than 20% knew that surviving COVID-19 does not provide lifelong immunity.We believe that such reasoning can negatively affect the use of methods to prevent the future episodes of the disease once it has been contracted.However, further research is needed.Migrants distinguished themselves with the highest knowledge regarding the fact that COVID-19 is a highly contagious disease.This information often appeared in the media which may have influenced on the number of correct answers.However, almost half of the respondents chose the wrong answer, which could affect the spread of COVID-19.Notably, this message was identified in fake news appearing in social media since the beginning of the pandemic. [29]ata from the literature described an association between knowledge, high-income and education. [30]We have shown that knowledge level about COVID-19 was specifically low in those with self-reported poor SES.In general, individuals of lower SES have less health-related knowledge.Supporting this idea, research early in the COVID-19 epidemic found lower COVIDrelated knowledge among individuals of lower SES. [31,32]

Preventive practices towards COVID-19
We have shown that COVID-19 related preventive practices were inappropriate, particularly mask usage with uncovered nose.Appropriate masks usage is crucial to reduce the likelihood of SARS-CoV-2 infection due to the interruption of the virus transmission path. [33,34]roblems with maintaining appropriate practices in Ukraine often result from the lack of availability of personal protective equipment.At the beginning of the pandemic, masks were unavailable and then expensive. [35]This forced the population to use masks many times, which did not ensure adequate effectiveness.Part of seniors groups complained that masks are made a way which make them difficult to breathe; therefore they refrained from using them. [36] little more than a half of our respondents declared using masks in public spaces.This is less than reported in other published studies.For instance, research conducted in Poland showed that about 60.4% of participants declared the use of masks in public space. [37]Another observational study showed that the percentage of those using masks was 73.6% at the first time point, decreasing after a week to 66.5% and 2 weeks later to 65.7%. [38]However, when the study was conducted there were not mandatory masks wearing in public space.That fact may have contributed to the deterioration of practices.Residents   of Romania and Bosnia and Herzegovina showed cautious practices with as much as 95.7% and 91.9% of subjects respectively wearing a face mask while being outside of their home. [39,40]owever, a survey conducted in 38 countries on 13,723,810 participants shows that some countries such as Chile, Italy and Japan had consistently high mask usage (>75%) compared to the countries with low usage mask (<25%) (Denmark, Sweden, and Norway). [41]nly two-thirds of our respondents declared following coughing etiquette.Previous research suggests better adherence to coughing etiquette among refugees . [42]Four years of observing coughing etiquette of people in public locations, in the United States, resulted in observing less than 2 percent properly covering their nose and mouth while coughing or sneezing.Of note, that study was conducted before the COVID-19 pandemic. [43]urther research on following coughing etiquette is urgently needed.
The present study shows that a large majority of UR declared wearing mask with uncovered nose.This was in line with other study conducted in Japan that showed only 40.8% of participants placing the mask ensuring it covers the mouth and nose. [44]his may be due to the fact that masks are perceived as uncomfortable. [45]Masks usage in Japan have been introduced as a response to the Spanish flu in 1919.Since then, wearing a face mask has been entrenched as a protection against pollution and used as a general self-protective risk ritual. [46]Before the pandemic, there were no widely available recommendations about wearing masks in most of the countries.
Only 40.5% of UR declared keeping social distance.The results are in line with those reported in a study conducted in the United States which showed that only about one third of participants reported social distancing in May 2020. [47]However, most recent studies suggest more effective maintaining of social distancing; it was at a higher level than declared among UR. [42,48,49]he vast majority of our respondents declared that they stayed in home isolation during COVID-19 infection.This was concordant with the results of one previous survey published in the United Kingdom. [50]Better home isolation was reported among residents of Iran. [39]he better education level and higher knowledge scores was significantly associated with better practices scores, meaning that more educated participants with a high level of knowledge were engaged in more prevention practices.This might be due to the fact that these groups are more aware of health-seeking behaviors, better understand the preventive measures, the rationales for their use and their impact on health. [40]Similar results were reported by Šljivo et al; [51,52] subjects who had higher knowledge test score were more prone to respect socio-epidemiological measures, such as wearing a mask while outside the home.Other authors have also previously reported associations when performing knowledge, attitudes and practices surveys in some other infectious diseases. [53]Better knowledge may result in good practices, thus aiding in the prevention and management of infectious diseases.Our study may help to set national public health campaigns priorities in order to address the most misunderstood and hazardous practices.

Limitations
A key limitation of the current study was the small sample size which may influence the generalizability.This was due to the small number of refugees who registered in the refugee center in the dedicated time period.Additionally, the convenience sampling is another shortcoming of our survey.Convenient sampling has disadvantages related to population bias that may limit the extrapolation of the results in the target population.The study employed a convenient sample since time is of essence in COVID-19 research and thus the sample may not be representative of all UR in Poland.Nevertheless, we believe that the data presented here could be considered as a satisfactory reflection of the knowledge, and practices of UR regarding SARS-CoV-2 infection prevention, given that our sample included migrants which differed regarding age, gender, residency in Ukraine, marital status and education level.Second, data was collected only in one refugee center.Further studies should be conducted in other parts of the country, varying in terms of population size and region.Third, questionnaire was distributed in Ukrainian language.Therefore, UR may not fully understand the questions.However, if a question was difficult to understand, respondents could get help from research team member present on the site.Fourth, while we highlighted some variables regarding the UM demographic, other factors, for example, religion, as well as masks availability and affordability might have also influenced risky practices.Finally, we did not make an objective assessment of practices.Migrants could make answers, which they thought as the most desirable.

Conclusions
We found that knowledge and practices regarding nonspecific methods of preventing SARS-CoV-2 infection among UM in Poland were unsatisfactory.Efforts should be made to improve knowledge and practices in this group to better control the pandemic.Health education programs should be implemented on the national and regional level to effectively raise the COVID-19 knowledge level and better equip UR with COVID-19 prevention skills.Health education programs should be prepared in a language understood by refugees, in particular among those with lower education and lower SES.
The authors have no funding and conflicts of interest to disclose.The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.Anonymous cross-sectional surveys, like this one, do not require the consent of the Bioethical Committee Collegium Medicum University of Zielona Gora in Poland.
a Student Research Group, Collegium Medicum, University of Zielona Gora, Zielona Gora, Poland, b Department of Methods of Artificial Intelligence and Applied Mathematics, West Pomeranian University of Technology, Szczecin, Poland, c Department of Infectious Diseases, Collegium Medicum, University of Zielona Gora, Zielona Gora, Poland.

Table 5
Logistic regression model: association of COVID-19 preventive practices with selected variables: estimates and P values (n = 190).